CAMPER INFORMATION Name: Birthday: Age at camp: Gender: m Male m Female Address: City: Postal Code: Home Phone Number: Session: mAM (9:00am - 12:00pm) - 7-12 years old mPM (1:00pm - 4:00pm) - 13-17 years old Tshirt: Youth mS mM mL or Adult mS mM mL Camp Week: mJuly 7-11, 2014 mJuly 14-18, 2014 PARENT 1/PRIMARY CONTACT Name: Work Phone: Home/Cell Phone: Address: (if different than camper) Email: Does your camper require bussing? mYes mNo CUSTODY OF CAMPER Please Specify: m Mother Only m Father Only m Both m Other: I understand and permit pictures of my child to be taken at camp and used for promotional purposes for the YMCA of Western Ontario mYes mNo #1 EMERGENCY CONTACT/AUTHORIZED PICK UP *MANDATORY* #2 EMERGENCY CONTACT/AUTHORIZED PICK UP Name: (other than parent) Home Phone: Name: (other than parent) Home Phone: Relationship to camper: Work/Cell Phone: Relationship to camper: Work/Cell Phone: MEDICAL INFORMATION Does your child have any of the following? m ADD m ADHD m OCD Please list any medical or dietary conditions we should be aware of: Please list any medications that your child requires while at camp: ASSISTANCE / PAYING FOR CAMP Please list your monthly income (net, after taxes/deductions) _________________. Please send proof of income with your completed registration form. If you wish to pay for camp please check here m $100/members, $140/non members. Payment can be made in the branch or send a cheque with your registration form. Please make cheques out to YMCA of Western Ontario. Participants will receive confirmation via phone/email within 2 weeks of registration form being recieved. I permit my child noted above to attend camp at the YMCA of Western Ontario. I permit my child to participate in the full range of camp activities and authorize the YMCA in the event of an accident or illness affecting the above child to authorize on my behalf all procedures including admission to the hospital and necessary treatment therein, as she/he may deem essential for the care and well-being of said camper. Such action is to be taken only when immediate contact with the undersigned cannot be made. Signature of Parent/Guardian: Date Signed: YMCA London Lightning Basketball Camp July 7 - 11, 2014 & July 14-18, 2014 YMCA of Western Ontario ymcawo.ca LONDON LIGHTNING BASKETBALL CAMP REGISTRATION mNorthbrae mSt. Anne m St. Pius mSt. Frances